Nursing Interventions
A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse
rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low.
Which of these orders by the health care provider will the nurse question?
a. Give furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 150 mL/hr.
c. Administer hydrocortisone (SoluCortef) 100 mg IV.
d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.
a. Give furosemide (Lasix) 40 mg IV.
Furosemide will lower the filling pressures and renal perfusion further for the patient
with septic shock. The other orders are appropriate.
A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP
92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following
collaborative interventions prescribed. Which intervention will the nurse question?
a. Infuse normal saline at 250 mL/hr.
b. Keep head of bed elevated to 30 degrees.
c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg.
d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
a. Infuse normal saline at 250 mL/hr.
The patient's elevated pulmonary artery wedge pressure indicates volume excess. A
normal saline infusion at 250 mL/hr will exacerbate this. The other actions are
appropriate for the patient.
Which of these findings is the best indicator that the fluid resuscitation for a patient with
hypovolemic shock has been successful?
a. Hemoglobin is within normal limits.
b. Urine output is 60 mL over the last hour.
c. Pulmonary artery wedge pressure (PAWP) is normal.
d. Mean arterial pressure (MAP) is 65 mm Hg.
b. Urine output is 60 mL over the last hour.
Assessment of end-organ perfusion, such as adequate urine output, is the best indicator
that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are
useful in determining the effects of fluid administration, but they are not as useful as data
indicating good organ perfusion.
A patient with massive trauma and possible spinal cord injury is admitted to the
emergency department (ED). Which finding by the nurse will help confirm a diagnosis of
neurogenic shock?
a. Cool, clammy skin
b. Inspiratory crackles
c. Apical heart rate 48 beats/min
d. Temperature 101.2° F (38.4° C)
c. Apical heart rate 48 beats/min
Neurogenic shock is characterized by hypotension and bradycardia. The other findings
would be more consistent with other types of shock.
A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring
indicates a high systemic vascular resistance (SVR). Which action will the nurse
anticipate taking?
a. Increase the rate for the prescribed dopamine (Intropin) infusion.
b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion.
c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion.
d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.
d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.
Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which
will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not
directly increase SVR. Increasing the dopamine will tend to increase SVR.
To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patient
with systemic inflammatory response syndrome (SIRS), which assessment will the nurse
make?
a. Auscultate bowel sounds.
b. Ask the patient about nausea.
c. Monitor stools for occult blood.
d. Check for abdominal distention.
c. Monitor stools for occult blood.
Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill
patients. The other assessments also will be done, but these will not help in determining
the effectiveness of the omeprazole administration.
Which intervention will the nurse include in the plan of care for a patient who has
cardiogenic shock?
a. Avoid elevating head of bed.
b. Check temperature every 2 hours.
c. Monitor breath sounds frequently.
d. Assess skin for flushing and itching.
c. Monitor breath sounds frequently.
Which intervention will the nurse include in the plan of care for a patient who has
cardiogenic shock?
a. Avoid elevating head of bed.
b. Check temperature every 2 hours.
c. Monitor breath sounds frequently.
d. Assess skin for flushing and itching.
After receiving 1000 mL of normal saline, the central venous pressure for a patient who
has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse
will anticipate the administration of
a. nitroglycerine (Tridil).
b. drotrecogin alpha (Xigris).
c. norepinephrine (Levophed).
d. sodium nitroprusside (Nipride).
c. norepinephrine (Levophed).
When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase
systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin
would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha
may decrease inappropriate inflammation and help prevent systemic inflammatory
response syndrome, but it will not directly improve blood pressure. Nitroprusside is an
arterial vasodilator and would further decrease SVR.
The emergency department (ED) receives notification that a patient who has just been in
an automobile accident is being transported to your facility with anticipated arrival in 1
minute. In preparation for the patient's arrival, the nurse will obtain
a. 500 mL of 5% albumin.
b. lactated Ringer's solution.
c. two 14-gauge IV catheters.
d. dopamine (Intropin) infusion.
c. two 14-gauge IV catheters.
A patient with multiple trauma may require fluid resuscitation to prevent or treat
hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to
administer normal saline. Lactated Ringer's solution should be used cautiously and will
not be ordered until the patient has been assessed for possible liver abnormalities.
Although colloids may sometimes be used for volume expansion, crystalloids should be
used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the
initial therapy for hypovolemic shock.
When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion
to treat cardiogenic shock, which finding indicates that the medication is effective?
a. No heart murmur is audible.
b. Skin is warm, pink, and dry.
c. Troponin level is decreased.
d. Blood pressure is 90/40 mm Hg.
b. Skin is warm, pink, and dry.
Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since
nitroprusside is a vasodilator, the blood pressure may be low even if the medication is
effective. Absence of a heart murmur and a decrease in troponin level are not indicators
of improvement in shock.
Which information obtained by the nurse when caring for a patient who has cardiogenic
shock indicates that the patient may be developing multiple organ dysfunction syndrome
(MODS)?
a. The patient's serum creatinine level is elevated.
b. The patient complains of intermittent chest pressure.
c. The patient has crackles throughout both lung fields.
d. The patient's extremities are cool and pulses are weak.
a. The patient's serum creatinine level is elevated.
The elevated serum creatinine level indicates that the patient has renal failure as well as
heart failure. The crackles, chest pressure, and cool extremities are all consistent with the
patient's diagnosis of cardiogenic shock.
A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126,
respirations 30. The PAWP is increased and cardiac output is low. The nurse will
anticipate
a. infusion of 5% human albumin.
b. administration of furosemide (Lasix) IV.
c. titration of an epinephrine (Adrenalin) drip.
d. administration of hydrocortisone (SoluCortef).
b. administration of furosemide (Lasix) IV.
The PAWP indicates that the patient's preload is elevated and furosemide is indicated to
reduce the preload and improve cardiac output. Epinephrine would further increase heart
rate and myocardial oxygen demand. Normal saline infusion would increase the PAWP
further. Hydrocortisone might be used for septic or anaphylactic shock.
A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32,
temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed
interventions will the nurse implement first?
a. Give normal saline IV at 500 mL/hr.
b. Infuse drotrecogin- (Xigris) 24 mcg/kg.
c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to
70 mm Hg.
a. Give normal saline IV at 500 mL/hr.
Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid
resuscitation is the initial therapy. The other actions also are appropriate and should be
initiated quickly as well.
Which assessment is most important for the nurse to make in order to evaluate whether
treatment of a patient with anaphylactic shock has been effective?
a. Pulse rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
d. Oxygen saturation
Because the airway edema that is associated with anaphylaxis can affect airway and
breathing, the oxygen saturation is the most critical assessment. Improvements in the
other assessments also will be expected with effective treatment of anaphylactic shock.
During change-of-shift report, the nurse learns that a patient has been admitted with
dehydration and hypotension after having vomiting and diarrhea for 3 days. Which
finding is most important for the nurse to report to the health care provider?
a. Decreased bowel sounds
b. Apical pulse 110 beats/min
c. Pale, cool, and dry extremities
d. New onset of confusion and agitation
d. New onset of confusion and agitation
The changes in mental status are indicative that the patient is in the progressive stage of
shock and that rapid intervention is needed to prevent further deterioration. The other
information is consistent with compensatory shock.
A patient is treated in the emergency department (ED) for shock of unknown etiology.
The first action by the nurse should be to
a. administer oxygen.
b. attach a cardiac monitor.
c. obtain the blood pressure.
d. check the level of consciousness.
a. administer oxygen.
The initial actions of the nurse are focused on the ABCs—airway, breathing,
circulation—and administration of oxygen should be done first. The other actions should
be accomplished as rapidly as possible after oxygen administration.
A patient who has been involved in a motor vehicle crash is admitted to the emergency
department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these
prescribed interventions should the nurse implement first?
a. Place the patient on continuous cardiac monitor.
b. Draw blood to type and crossmatch for transfusions.
c. Insert two 14-gauge IV catheters in antecubital space.
d. Administer oxygen at 100% per non-rebreather mask
d. Administer oxygen at 100% per non-rebreather mask
The first priority in the initial management of shock is maintenance of the airway and
ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for
transfusions also should be rapidly accomplished, but only after actions to maximize
oxygen delivery have been implemented.
When caring for a patient who has septic shock, which assessment finding is most
important for the nurse to report to the health care provider?
a. BP 92/56 mm Hg
b. Skin cool and clammy
c. Apical pulse 118 beats/min
d. Arterial oxygen saturation 91%
b. Skin cool and clammy
Since patients in the early stage of septic shock have warm and dry skin, the patient's
cool and clammy skin indicates that shock is progressing. The other information also will
be reported but does not indicate deterioration of the patient's status.
Norepinephrine (Levophed) has been prescribed for a patient who was admitted with
dehydration and hypotension. Which patient information indicates that the nurse should
consult with the health care provider before administration of the norepinephrine?
a. The patient's central venous pressure is 3 mm Hg.
b. The patient is receiving low dose dopamine (Intropin).
c. The patient is in sinus tachycardia at 100 to 110 beats/min.
d. The patient has had no urine output since being admitted
a. The patient's central venous pressure is 3 mm Hg.
Adequate fluid administration is essential before administration of vasopressors to
patients with hypovolemic shock. The patient's low central venous pressure indicates a
need for more volume replacement. The other patient data are not contraindications to
norepinephrine administration.
Which information about a patient who is receiving vasopressin (Pitressin) to treat septic
shock is most important for the nurse to communicate to the heath care provider?
a. The patient's heart rate is 108 beats/min.
b. The patient is complaining of chest pain.
c. The patient's peripheral pulses are weak.
d. The patient's urine output is 15 mL/hr.
b. The patient is complaining of chest pain.
Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery
perfusion. The other information is consistent with the patient's diagnosis and should be
reported to the health care provider but does not indicate a need for a change in therapy.